Malaria DiplomacyIn Myanmar, DGHI researchers are working to control the threat of drug-resistant malaria by building trust among its divided factions.

By Michael Penn

In the summer of 1999, Myaing Myaing Nyunt was working in a mobile health clinic in a remote part of Thailand near the Myanmar border when two young men forded a shallow river that separated the two countries. From their cropped hair and accent, Nyunt, a native of Myanmar who was then completing medical school in the United States, recognized them as soldiers, part of the military junta that had been locked in a decade-long conflict with ethic groups in the region. She could also see they were sick, their bodies trembling with malarial chills.

“They were risking their lives by crossing the border into rebel territory,” says Nyunt. “But they were suffering.”

Clinic workers, many of whom were members of the ethnic group the military was fighting, gave the men antimalarial pills, handing them extras for others in their camp who were sick. Over the next few weeks, more men crossed the river, usually in pairs, never disclosing their identities. They all received care—and no further questions.

Myaing Myaing Nyunt has been conducting malaria research in Myanmar since 2010.

The small acts of cooperation made an impression on Nyunt, who is now an associate professor of medicine and global health at Duke. “Here we are, these two groups that are fighting on a political level,” she recalls. “But on a human level, people are helping each other. That stuck with me.”

Two decades later, Nyunt is again working in Myanmar, leading a research program to help her native country gain a foothold in its long fight against malaria. And though Myanmar continues to be riven by violence and ethnic conflict, the long-ago encounter remains fresh in her mind, kindling a hope that ending malaria may be one thing about which Myanmar’s myriad rivals can agree.

More than 115,000 people in Myanmar contract malaria each year, among the highest rates in Southeast Asia. And while that number has declined significantly in the past decade—thanks to effective drugs and heightened efforts to prevent and control the mosquito-borne disease—Myanmar and its neighboring countries have a nasty history of birthing new forms of the parasite that defy treatment. In the past few years, studies have shown parasites in the region are growing increasingly resistant to artemisinin, the most effective drug against malaria, igniting fears that the disease may be gearing up for a comeback in Southeast Asia.

The growing threat of drug resistance reinforces Nyunt’s belief that the only acceptable number of malaria cases in Myanmar is zero. Wiping out the disease completely, she says, is the surest way to keep dangerous new forms of the parasite from spreading—and possibly sparking a new global pandemic.

“There is an urgency to this work,” she says. “If we are going to eliminate malaria, we have to have an impact on policy right away.”

Nyunt has been working toward that goal since 2010, when she returned to Myanmar as an assistant professor with the Johns Hopkins University School of Medicine. With her research collaborator and husband, Chris Plowe, she earned the first National Institutes of Health grant to conduct malaria research in Myanmar, which was focused on molecular epidemiology of drug-resistant forms of the disease. They have since earned the designation of one of NIH’s International Centers of Excellence for Malaria Research, based in Myanmar with additional sites in China and Bangladesh.

Plowe’s 2018 appointment as director of the Duke Global Health Institute brought the team to Duke, where it is continuing its work to identify and track the spread of drug-resistant parasites. Shortly after arriving at Duke, Nyunt received a grant from the Bill & Melinda Gates Foundation to test a more sensitive diagnostic tool that delivers results at the point of test, which could help health workers in the field spot troublesome cases before they spread.

But the team’s work is also notable for its emphasis on building common ground among disparate and often contentious factions within Myanmar, groups that have long histories of suspicion and confrontation.

“Myaing’s idea has been to use the shared goal of combating malaria to create new trust and cooperation among diverse groups in Myanmar,” says Plowe. “And hopefully, that creates a way to foster wider social and political change.”

For the past several years, Nyunt has crisscrossed Myanmar to knit together a complex web of government agencies, community groups and non-government organizations who now collaborate on their research. She notes with pride that her first Gates grant listed eight official partners, including three units within the Myanmar health ministry and four non-governmental groups working in remote parts of the country. “We brought these eight groups together to work under one protocol, and that had never happened before in Myanmar.”

A 2015 malaria elimination event at the Center for Strategic and International Studies included senior government officials and Members of Parliament from the then-ruling military party and the then-opposition party, as well as members of ethnic health organizations attached to ethnic militias then in active conflict with the government.

And there are signs of growing cooperation. In 2015, a few months before Myanmar elected its first pro-democracy government in decades, Plowe and Nyunt worked with the Center for Strategic and International Studies (CSIS), a Washington, D.C.-based policy group, to organize a meeting of more than a dozen of the country’s political and military leaders to hammer out a common agenda for malaria eradication. The attendees included representatives of ethnic groups that had been in armed conflict with the military for years—“people who hadn’t ever sat down at the same table,” says Plowe. But they managed to find consensus over malaria.

“Malaria provided the hook in that it represented a common concern,” says Stephen Morrison, director of global health policy for CSIS. “It became less of a political problem and more of a public health problem.” He credits Nyunt for her patient diplomacy in convincing the parties to participate and winning the trust of the ethnic groups. “They felt they would be trusted and have a voice at the table.”

Nyunt at the 2015 CSIS malaria elimination event, with Admiral Tim Ziemer, then the U.S. President’s Malaria Initiative leader, Dr. Tin Maung Hlaing and Saw Diamond Khin, a member of the Karen ethnic health organization.

That cooperation has endured. Nyunt says Myanmar’s health ministry is sharing more information with foreign NGOs and performing research to inform their work. Government officials are also reaching out to community health workers aligned with ethnic groups, she says.

“It used to be that the government didn’t really want much to do with foreign researchers or outside NGOs,” says Neeraj Kak, a scientist with the University Research Corporation who has been working in Myanmar since 2011 and has collaborated with Nyunt to test diagnostic tools in the field. “There’s a lot more openness now. I think they understand this is a health issue, and they need to do better for their own people.”

Forging partnerships in a fragile country does have complications. While Myanmar’s civilian government has restored diplomatic relations and negotiated peace with several militant groups, allegations of grave human rights abuses persist. In Rakhine state along Myanmar’s western border, military forces are accused of waging a genocidal campaign against Rohingya Muslims, killing thousands and causing an estimated half million Rohingya to flee. Political leader Aung San Siu Kyi, once heralded as an icon of Myanmar’s democratic promise, has been widely criticized by international watchdogs for turning a blind eye on the Rohingya crisis.

Like all researchers in conflict zones, Plowe and Nyunt follow guidelines set by the U.S. government about whom they work with. All of their collaborators are doctors and scientists in the country’s health ministry and military medical corps, which controls access to many remote field clinics where malaria is endemic. But they are keenly aware of the questions raised by collaborating with institutions so closely linked to heinous acts.

“It’s something I struggle with,” says Nyunt. “Can we have a diplomatic relationship with a government that has been accused of such human rights abuses and still protect our values? Do we just walk away? Or do we continue working with people within the government to educate and bring about change?”

Nyunt knows the weight of those choices better than most. In 1988, she was in her final year of medical school at the University of Yangon when students across the country organized massive protests against its military regime. She was among the crowd when military troops mobilized to break up the protests, triggering days of violent riots that left hundreds of protesters dead.

Nyunt (far left) as a fifth-year medical student at the University of Medicine 1 in Yangon in 1987.

Thousands of students fled. Nyunt spent a year living in rebel camps near the border of Thailand—the same region where she would encounter the ailing soldiers years later--before an international health agency helped her emigrate to the United Kingdom. She went on to the United States, where she completed her medical training and earned a Ph.D. in clinical investigation.

For most of that time, Nyunt had no designs to return to Myanmar, which grew increasingly isolated under international economic and political sanctions. But in 2007, she watched news reports of another military crackdown, this time against protests led by Burmese monks.

“This time the world was watching, and still nothing happened,” she says. “I had to do something to help the people within the country who were fighting for change.”

Medical students proudly display their certificates of completion for an ethics and professionalism workshop in Yangon, Myanmar, taught by Nyunt (center, in black).

Malaria research has been a surprisingly agile platform. In 2013, for example, Nyunt secured funding from the Open Society Foundation to train her research partners on international research ethics, which allowed her to engage them in conversations about consent and respect for participants’ privacy and autonomy. The Duke team has since led dozens of these sessions for government officials, community health workers and even soldiers.

The implied lesson is that these principles apply not just to malaria research, but in larger society. And on at least one occasion, that message has taken root: Nyunt relates a story of a government official showing her a stack of ethics guidelines several inches thick that she had printed from the NIH website.

“This is good stuff,” she whispered to Nyunt with an air of conspiracy. “It’s all about human rights.”

No one suggests that malaria research alone will transform Myanmar’s fractious politics. As Morrison notes, the diplomatic gains from the project “are important, but modest.” But as the country emerges from decades in the darkness, there is hope in even the smallest moments of understanding—something Nyunt learned twenty years ago when two men crossed a border to seek help.

“I really believe that people are capable of change and willing to change,” she says. “It’s not going to happen overnight. We will see ups and downs in the process of building democracy. But people must take individual responsibility in any way that they can and that they believe in. We believe science will contribute positively to bringing about that change.”